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The new dangers of vaping

About the author:&nbsp

Cate Montana

Vaping was supposed to be the ‘safe’ way to wean yourself off tobacco. But, as Cate Montana learns, it comes with a new set of dangers

Everybody knows cigarettes are terrible for your health. Tobacco smoke contains over 7,000 chemicals, at least 70 of which are known to cause cancer, with countless others causing emphysema, heart disease and a whole raft of other health problems. But at least people know the likely consequences if they do light up.

With electronic vaporisers—or 'vaping' the common term for using a vaporizer—there is no such guarantee. Little is known about the health consequences of using these colourful and stylishly trendy ENDS (electronic nicotine delivery systems). They come in a variety of forms, from e-cigs that look like cigarettes, complete with a red tip that glows on every inhalation, to e-pipes, e-hookahs and e-cigars. Some ENDS are fashioned to look like everyday objects such as pens or USB thumb drives.

But no matter the colour, shape or name of the device, they're all designed to allow users to inhale an aerosol vapour that contains nicotine.

Most e-cigarettes are battery-operated and use a heating element to heat the 'e-liquid'—usually either glycerine or propylene glycol mixed with nicotine, extracted from tobacco—in a refillable cartridge.

The e-liquid is heated, on average, to between 200-250° C (392-482° F), and then released to be inhaled as a vapour.

Propylene glycol is a colourless, slightly sweet-tasting, synthetic compound—also called 'propane-1,2-diol'—used in the production of polymers (mostly plastics) and in food-processing. Glycerine is a colourless, slightly sweet-tasting, organic compound derived from animal fats and vegetable oils. The e-liquid can also include flavourings and other chemicals as well.

Invented in China in 2003, e-cigs have gained popularity at an astonishing rate ever since they hit the global market in 2007. Hailed as 'the answer' to avoiding the health risks associated with tobacco and a viable product to help wean people off tobacco, what swiftly became fashionably known as 'vaping' took off.

According to the American Lung Association, in 2015, 3.7 per cent of US adults were e-cigarette users. Of that group, 59 per cent were still current cigarette smokers, 30 per cent were former cigarette smokers and 11 per cent had never smoked cigarettes.

With a $3.7 billion annual market in the US alone, it should come as no surprise that there are more than 500 brands of e-cigarettes touting some 7,700 flavours to supply the ever-growing demand. This tidal wave of interest even prompted some big tobacco companies like Reynolds and Altria to jump into production, and their products are now best-sellers. However, most of the brands that have hit the streets are made by unknown start-up companies scattered all over the world.

Unregulated and untested

Aside from the base liquids and nicotine, the chemical additives and ingredients found in many, if not most, e-cigs are uncertain, as labelling is sketchy at best. In addition, according to the American Lung Association, there is: (1) little consistency in the nicotine contents of e-cigarettes, even among those of the same brand; (2) e-liquid refills often have a nicotine content that varies from the amount cited on the label; and (3) some 'nicotine-free' e-cigarettes do, in fact, contain traceable levels of nicotine.

Aside from being addictive, nicotine is also a poison. Numerous studies carried out over the years on smokeless nicotine delivery systems, such as chewing gum, lozenges, mouth sprays and transdermal patches, indicate that poisoning can happen in children after the accidental ingestion of 1 mg of nicotine per kg of body weight and that a similar dose may even be fatal in adults.1 As an e-liquid refill can contain 24 mg of nicotine, this equates to 0.4 mg of nicotine per kg in a 60-kg (130-lb) user, while the lethal per-kg dose in adults is 0.5-1.0 mg, and probably as little as 0.1-0.2 in children.2 So far, at least one child in the US has died due to ingesting liquid nicotine by mistake.

But as one letter from a Washington State University researcher states, "Even at lower levels of nicotine than expected, given manufacturer specifications, these nicotine solutions could be toxic or lethal if taken other than directed."3 Indeed, among nine cases of the use of nicotine patches and other such products in attempts at self-poisoning suicide,4 one described a 24-year-old woman who died after deliberately swallowing as much as 3,000 mg of e-liquid nicotine intended for e-cigarette use.5

Unregulated flavourings in e-cigarette liquids have also been a cause for concern. Just because the flavouring ingredients are legally acceptable for use in food products doesn't mean that they're safe to inhale through vaping.

For years, researchers and doctors have been calling for more rigorous controls and testing of all ENDS, and Western governments have responded. In May 2016, the EU's revised Tobacco Products Directive (TPD) developed in 2014 came into effect. The revision sets out new regulations covering e-cigarettes that require child-resistant, tamper-proof packaging, smaller cartridge sizes and a consistently delivered dose of nicotine, as well as a limited total dose of no more than 20 mg/mL of nicotine.

In the US, the Food and Drug Administration (FDA) required e-cigarette manufacturers to register with the FDA by August 2016, and gives them two years to apply for continued manufacturing rights. Companies are also now required to supply a detailed list of every product's ingredients, as well as any research findings on the impact of their products on public health.

Early studies of e-cigarettes were cautiously optimistic and indicated that e-cigarettes were potentially a safe substitute for tobacco products—or, at the very least, an "effective harm-reduction tool"—but always with the caveat that clinical studies still needed to be done to determine their safety when used in the long term.6

In August 2015, a couple of "expert independent evidence" reviews published by Public Health England (PHE) made the enthusiastic statements that e-cigarettes are "around 95 per cent less harmful than tobacco" and that "around 400,000 people" in the UK had quit smoking tobacco products solely because of e-cigarettes.7

Another study reported that 39.5 per cent of smokers in the UK used e-cigarettes to quit tobacco, a far-higher statistic than obtained for licensed NRT (nicotine replacement therapy) at 26.4 per cent, while varenicline (Chantix/Champix)—a drug that mimics nicotine by interfering with nicotine receptors in the brain—came in at a lowly 6.5 per cent success rate.8

Articles with titles like "E-cigarettes help up to 22,000 smokers in England quit each year"9 have reinforced the public perception that e-cigarettes and other vaping products are not only safe, but highly effective for helping people get off tobacco, firing up the hopes of the two out of three cigarette-smokers around the world who say they want to quit.

But according to Dr Sheri Jacobson, addiction expert and clinical director of Harley Therapy in London, addiction is a way to evade emotional stress and pain by keeping the mind and body busy. "This is why often, unless they have proper support, when a person quits one addiction, they tend to just replace it with another," she says.

Some studies reveal that e-cigarettes not only aren't particularly effective at helping to quit smoking, but actually encourage people—especially young adults and children—to pick up the nicotine habit. A recent major review and pooled analysis of 38 studies showed that the odds of people quitting smoking by using e-cigarettes were 28 per cent lower compared with those who didn't vape.10

In another, earlier study, e-cigarette use was not associated with any change in cigarette use at all.11 One reason for this may be that vaping continues to reinforce the 'hand-to-mouth' oral activity that goes with regular smoking, so sustaining the "smoker identity".12

"Vaping is considered a cure for getting off cigarettes," says Richard Sirota, a chemical-dependency therapist at a medical centre in Bellevue, Washington. "But frankly, I think it's just nicotine in another form. In some ways, it's less harmful to the lungs. But it's still very addictive."

Sirota points out that easy access and the perception of safety, combined with the addictive quality of nicotine itself, means that people will persist in puffing. And now that manufacturers are marketing ENDS as fashion accessories, the devices can now be worn around their necks for quick access. "All this means is that the habit is super-reinforced," he says.

In the face of conflicting reports about e-cigarettes helping people kick the tobacco habit, perhaps one of the most telling indicators of the true state of affairs is the fact that, despite people's desperation to quit smoking and the marketing power claiming e-cigarettes are the answer, so far, not a single US company manufacturing e-cigarettes has submitted an application to the FDA to approve the devices for tobacco cessation.

A host of problems

In fact, the more researchers look into the physical effects of nicotine and other e-liquid chemicals, the more troubling the whole vaping scenario becomes.

Whether through smoking tobacco or sucking on an e-cigarette, nicotine affects the brain's 'reward' system by increasing dopamine concentrations. It also mimics the body's acetylcholine neurotransmitters, causing the body to release noradrenaline (norepinephrine). Both dopamine and noradrenaline are what give the user that euphoric 'comfort feeling' that is so addictive.

In addition, the data suggest that nicotine can affect associative learning and alter memory processes, both of which can increase its addictive qualities.13 Nicotine addiction happens because users are quickly conditioned to depend on nicotine to positively enhance their mood and to avoid unpleasant withdrawal symptoms, including irritability, anxiety and stress.14

The US Surgeon General has stated that exposure to nicotine can harm a developing foetus by adversely affecting the development of the brain and lungs in newborns. Nicotine absorption by the mother can also result in low birth weight, premature delivery and even stillbirth. Nicotine has even been found to be a potential contributor to sudden infant death syndrome (SIDS).15

What's more, nicotine has also proved to be a potential 'gateway' drug for other addictive substances. An experiment with mice showed that nicotine has what's known as a "priming" effect in the brain for cocaine, making the latter drug more powerful and addictive in nicotine-exposed mice. This finding correlates with data showing that the majority of people who start using cocaine do so while smoking cigarettes.16

Tests of glycerine and propylene glycol, the main agents in e-cigarette liquids, show that, at vaping temperatures, both break down into various carbonyl compounds, including formaldehyde and acetaldehyde—both of which are known carcinogens. Propylene glycol generates more carbonyls than glycerine, and the higher the vaping voltage, the higher the formaldehyde, acetaldehyde and acetone levels.17

In many of the e-cigarettes tested, more than 2 per cent of the total solvent molecules from propylene glycol were converted into formaldehyde-releasing agents at higher concentrations than nicotine itself. One study has suggested that long-term inhalation of gaseous formaldehyde through vaping may present five to 15 times the cancer risk as smoking ordinary cigarettes.18

Flavouring chemicals in e-liquids such as diacetyl (DA) and acetyl propionyl (AP) have been found in nearly three out of four e-liquids tested. While certified as safe for food consumption, both DA and AP can cause respiratory disease if inhaled.19 In addition, many flavouring agents are aldehydes, a class considered to be 'primary irritants' in the lungs.20

Aimed at youth

Bubblegum, popcorn, gummy bear, candy cane, cotton candy . . . these are just some of the designer vaping-liquid flavours aimed at hooking children. E-cigarettes are glamourized in ads by manufacturers and tobacco companies, and are easily purchased by children online. One study showed a successful online buy rate of 94 per cent by youngsters aged 14 to 17, and none of the delivery companies made any attempt to verify the ages of the recipients—and nearly all deliveries were simply left at the door.21

The US Centers for Disease Control and Prevention (CDC) found that e-cigarette use among high-school and middle-school students has increased by more than 10-fold and by ninefold, respectively, since 2011. They also found that a combined total of three million high-school and middle-school students were using e-cigarettes in 2015.22

An article in the February 2016 issue of the journal Pediatrics by Alain Braillon, public-health senior consultant and whistle-blower, bluntly stated that "ENDS [electronic nicotine delivery systems] have the potential to addict a new generation of youth to nicotine and reverse more than 50 years of progress in tobacco control".23

"As a psychologist," says Matt Goldenberg, based in Olympia, Washington, "I am concerned with a new product that is known to be harmful and addictive to the public and yet appears to be a popular choice. Specifically, I am concerned about the past use of target marketing of minorities and young people that Big Tobacco has really profited from."

Sirota concurs. "E-cigs are becoming as popular as cigarettes," he says. "And they're especially attractive to youth. It's a really sad state of affairs. Cigarette usage was really reducing and now here comes vapes."

All this and explosions too

Smoking cigarettes may cause cancer—but at least you don't run the risk of having your lips and teeth blown away like you do with an ENDS.

Lithium-ion batteries produce about two times the voltage of traditional batteries. They can explode if internal electrical components short circuit, if there is some sort of mechanical damage or if the battery is subjected to too much heat—usually between 60-177° C (140-350° F). Lithium batteries are used because they are able to store large amounts of energy, but they can sometimes overheat and cause an ever-increasing energy loop called 'thermal runaway', resulting in spontaneous combustion.

The spectre of an exploding e-cigarette in your mouth or hand is grim. Severe burns and lung damage, tongue lacerations, facial fractures, second-degree burns on the face, ears and neck, shattered neck vertebrae, broken necks and shattered teeth are common when an e-cig explodes in the mouth. Finger amputations sometimes have to be done when an e-cig explodes while being held. Burns can also involve the hips, thighs and legs when an e-cigarette explodes while being carried in a pocket or handbag. It can also cause serious concerns and disruptions, as recently experienced when an e-cig spontaneously combusted during an American Airlines flight.

As more and more people turn to vaping, and as burns and trauma centres become more aware of what's going on, the number of reported incidents is increasing. Susan Gregg, spokesperson for the Harborview Medical Center in Seattle, Washington, reports that, in the two months they've been keeping track of e-cigarette-related burns and trauma, 23 patients have so far been treated.

"Women usually carry them in their purse and men carry them in their pockets," she says. "But both men and women have come in with burns on their faces and hands, thighs and legs—depending on where the e-cig was being carried or held on their body at the time."

According to the Federal Emergency Management Agency (FEMA) in the US, the vast majority of e-cigarette explosions happen when the lithium batteries are being charged. A major culprit in this scenario is not using the approved battery charger for that particular ENDS product.

Lack of government oversight in the manufacture of e-cigarettes in the EU, UK and US has directly contributed to safety concerns. And the import of ENDS from second-world nations with limited oversight and safety standards increases the potential of purchasing a defective device, charger or refill cartridges.

E-cigarettes may be 'more healthy' than tobacco cigarettes, but inhaling chemicals and nicotine—no matter what the delivery system—is never a healthy choice. "I believe we will continue to see public misunderstanding of the e-cigarette as a safe alternative to the traditional cigarette," says Goldenberg.

"I'd encourage any nicotine user to speak to their healthcare provider about the risks of use and discuss other treatment options to stop the use of these harmful products."

As Dr Sheri Jacobson puts it, " The question isn't what is being used to deliver nicotine or how much nicotine is too much nicotine, it's when are you going to face the stress and emotional pain that drives you towards self-destructive behaviours in the first place?"

Of the 405 different physical symptoms reported with the use of e-cigarettes, 326 were negative. Most symptoms affected the mouth and respiratory system, although some were related to the nervous, circulatory and digestive systems too. Users experiencing negative symptoms often experienced more than one symptom at a time, indicating interactions across different systems.1 Reported symptoms include:

• High blood pressure

• Insomnia

• Stroke

• Cancers of the respiratory tract and blood

• Irregular heartbeats

• Wheezing and shortness of breath

• Lung inflammation

• Decreased immunity to colds and lung ailments

• Upset stomach

• Headache

• Dizziness and fainting

• Nervousness and agitation

The power of mental addiction

The negative symptoms of vaping aren't just physical. Many people start using e-cigarettes because it seems 'cool', and is regarded as a relatively harmless pastime. But once addicted to nicotine and the action of vaping itself, people realize they are powerless in the face of their cravings.

"Having a dependency affects a person's mental health," says Washington-based addiction therapist Richard Sirota. "Any 'have to' is a negative to a person's mental health. I know people who actually plan their lives around where and when they can smoke or drink. Over time, this eats at their self-confidence and their overall ability for maintaining self-control."

In addition, there is evidence that nicotine is a gateway drug to other agents. As self-control and self-confidence wear down and negativity builds, the user becomes more susceptible to other drugs. But even if this doesn't happen, there is still a price to pay.

"Vaping is a gateway to a lessened ability to make decisions and take control of your life," says Sirota.

Withdrawal effects

Nicotine addiction with ENDS can happen rapidly especially because: (1) some devices can be modified to deliver higher levels of nicotine; and (2) wearing an ENDS device as a fashion accessory (like a necklace, for example) makes the device even more readily available than traditional cigarettes.

• In February 2016, The Daily Mail newspaper ran a story about Mick Bennett, 47, who was severely burned when an ENDS device exploded in his pocket while roller-skating at a rink in Greater Manchester with his seven-year-old son, Michael. Severe burns led to a 10-day stay in Wythenshawe Hospital, where he received treatments that included skin grafts. He also suffered nerve damage and has lost some feeling in his leg.

• A 30-year-old New Jersey man attending a rock music concert sustained partial-thickness burns to his right leg and knee when the lithium battery of his e-cigarette exploded in his pocket, setting his trousers on fire.

• Panicked shoppers ran out of the Freehold Raceway Mall in New Jersey when a 29-year-old mother from suffered burns after her e-cigarette battery exploded inside her Louis Vuitton purse.

• In October 2016, a 24-year-old man lost eight front teeth in an e-cigarette blast, while four more teeth had to be removed during oral surgery. He also suffered cuts to his lips and gums as well as burns to his right eye.

•In November 2016, a 24-year-old woman suffered tears in her nose and upper lip when her nose ring was ripped out by an exploding e-cigarette.

Tips to help you quit smoking

There are many suggested methods for quitting, whether you're hooked on vaping or regular cigarettes. One of the most effective methods for breaking the nicotine habit recommended by addiction therapist Richard Sirota is cognitive behavioural therapy (CBT). Hypnotherapy also has a good record of success.

But if any such therapy is out of the question, it's important to start breaking the associations in your mind between e-cigs (and cigarettes) and certain actions like eating, drinking and talking on the phone.

If you like to smoke while talking on the phone, do something else instead. Get up from your desk or chair and walk around as you talk. If you smoke while drinking alcohol and coffee, don't light up with the first sip, but wait until your drink is almost done, then extend the wait period until the very last sip. At that point, it's much easier to eliminate the combination of drinking and smoking altogether.

This also applies for time-of-day associations. If you always light up first thing in the morning, wait until after breakfast. If you always smoke as you drive to work, wait until you're walking in from the parking lot. Finally, avoid situations and people that trigger the stress reactions that make you crave a smoke.

Other aids to quitting

• Drink lots of water as you taper off your nicotine use, and up the amount once you have quit—water helps to flush toxins out of your system